A 50-year-old man with moderate depression has been taking citalopram 40mg daily for 7 weeks with minimal improvement. His PHQ-9 score remains at 17. He has been adherent to medication and denies any side effects. He declined psychological therapy initially due to work commitments. What is the most appropriate next step in pharmacological management?
Q122
A 26-year-old woman presents to the emergency department with sudden onset breathlessness, chest pain, trembling, and fear of dying. Symptoms began 15 minutes ago while shopping. She has experienced three similar episodes in the past month. ECG shows sinus tachycardia at 115 bpm. Troponin, D-dimer, and chest X-ray are normal. She is currently symptom-free. What is the most appropriate immediate management?
Q123
A 31-year-old man with generalised anxiety disorder has been experiencing excessive worry about work performance, finances, and family relationships for 8 months. He reports difficulty controlling the worry, muscle tension, poor concentration, and disturbed sleep. He declined medication initially. After completing a 10-week high-intensity CBT programme, his GAD-7 score has reduced from 18 to 15. What is the most appropriate next step in management?
Q124
A 44-year-old woman presents with a 6-week history of low mood, reduced energy, and weight loss. She describes feeling worthless and guilty about minor past events. Her PHQ-9 score is 21. She has no past psychiatric history and takes no regular medications. Physical examination and routine blood tests are normal. What is the most appropriate first-line pharmacological treatment?
Q125
A 36-year-old woman presents with symptoms suggestive of depression. She describes low mood, reduced appetite, poor sleep, and diminished interest in activities for the past 5 weeks. During assessment, which of the following symptoms would be classified as a 'biological' (somatic) symptom of depression according to ICD-10 criteria?
Q126
A 52-year-old man with chronic generalised anxiety disorder has failed to respond adequately to sertraline 150mg daily and two courses of CBT over the past 18 months. His GAD-7 score remains at 15 and symptoms significantly impact his work and relationships. He has no history of substance misuse. His renal function is normal. Which of the following would be the most appropriate next pharmacological option?
Q127
A 45-year-old woman with moderate depression started on sertraline 50mg daily attends for review after 2 weeks. She reports nausea, loose stools, and increased anxiety. These symptoms started 3 days after beginning the medication. Her mood has not yet improved. She is considering stopping the medication due to side effects. What is the most appropriate management approach?
Q128
A 33-year-old woman with panic disorder and agoraphobia has completed 12 weeks of cognitive behavioural therapy with exposure work. She reports significant improvement with reduced panic frequency and increased confidence in previously avoided situations. However, she still experiences occasional panic attacks (once every 2-3 weeks) and mild anticipatory anxiety. What is the most appropriate next step in her management?
Q129
A 59-year-old man with recurrent depressive disorder has been taking fluoxetine 40mg daily for 2 years following his third depressive episode. He has been well for 18 months and asks about stopping his medication. According to current NICE guidance, what is the minimum recommended duration of maintenance treatment after a third or subsequent episode of depression?
Q130
A 37-year-old man with panic disorder describes that his panic attacks are always triggered by being in crowded places, particularly supermarkets and public transport. He has been avoiding these situations for 3 months. He has no unexpected panic attacks. His avoidance is significantly impacting his daily functioning. Which diagnosis best describes his presentation?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 121: A 50-year-old man with moderate depression has been taking citalopram 40mg daily for 7 weeks with minimal improvement. His PHQ-9 score remains at 17. He has been adherent to medication and denies any side effects. He declined psychological therapy initially due to work commitments. What is the most appropriate next step in pharmacological management?
A. Increase citalopram to 60mg daily
B. Add mirtazapine 15mg at night to the citalopram
C. Switch to venlafaxine 75mg daily (Correct Answer)
D. Continue citalopram for a further 4 weeks
E. Switch to fluoxetine 20mg daily
Explanation: ***Switch to venlafaxine 75mg daily*** - After a 6-8 week trial of a first-line **SSRI** at an adequate dose (citalopram 40mg daily) with minimal improvement, the recommended next step is to **switch antidepressants**, either to another SSRI or to a different class like an **SNRI**. - **Venlafaxine**, an **SNRI**, is a suitable second-line option for patients who have not responded to initial SSRI treatment, offering a different mechanism of action by inhibiting both **serotonin and norepinephrine reuptake**.*Increase citalopram to 60mg daily* - The **maximum licensed dose** for citalopram is **40mg daily** (or 20mg in the elderly) due to dose-dependent risks of **QT prolongation** and cardiac arrhythmias. - Increasing the dose beyond 40mg is contraindicated and would not be an appropriate clinical step according to relevant **NICE guidelines**.*Add mirtazapine 15mg at night to the citalopram* - **Augmentation strategies**, such as adding mirtazapine to an SSRI, are generally reserved for **treatment-resistant depression** after multiple monotherapy trials have failed. - Guidelines advise **switching monotherapy** first before moving to combination treatments to minimize side effect burden and potential drug interactions.*Continue citalopram for a further 4 weeks* - Clinical response to antidepressants is typically assessed at **4 weeks** and definitively at **6-8 weeks**; this patient has shown minimal improvement despite **7 weeks** of adherence. - Continuing a treatment that has already failed to produce a meaningful reduction in the **PHQ-9 score** over an adequate timeframe is unlikely to lead to further benefit and delays effective treatment.*Switch to fluoxetine 20mg daily* - While switching to another **SSRI** is a valid option, switching to a different drug class (like an **SNRI**) is often preferred when there has been a near-complete lack of response to the initial SSRI. - Given the patient's **moderate depression** and lack of response to a maximum tolerated dose of citalopram, a drug with a different mechanism of action might offer a better chance of efficacy.
Question 122: A 26-year-old woman presents to the emergency department with sudden onset breathlessness, chest pain, trembling, and fear of dying. Symptoms began 15 minutes ago while shopping. She has experienced three similar episodes in the past month. ECG shows sinus tachycardia at 115 bpm. Troponin, D-dimer, and chest X-ray are normal. She is currently symptom-free. What is the most appropriate immediate management?
A. Prescribe a 2-week supply of diazepam 5mg as required
B. Prescribe propranolol 40mg three times daily
C. Provide reassurance and psychoeducation about panic attacks (Correct Answer)
D. Commence escitalopram 10mg daily immediately
E. Arrange same-day psychiatric assessment
Explanation: ***Provide reassurance and psychoeducation about panic attacks***
- After ruling out life-threatening medical conditions like **myocardial infarction** or **pulmonary embolism** with normal investigations, the immediate priority is to reassure the patient.
- **Psychoeducation** helps the patient understand that their symptoms, though distressing, are not dangerous and are part of a **panic attack**, reducing their **catastrophic misinterpretation** of physical sensations.
*Prescribe a 2-week supply of diazepam 5mg as required*
- **Benzodiazepines** carry a high risk of **dependence** and **withdrawal symptoms**, making them generally unsuitable for the routine or long-term management of panic disorder.
- Current guidelines, such as those from NICE, specifically advise against the routine use of benzodiazepines for managing **panic disorder** due to these significant risks.
*Prescribe propranolol 40mg three times daily*
- **Beta-blockers** like propranolol primarily target **autonomic symptoms** such as **tachycardia** and **trembling**, but they do not address the core psychological component of a panic attack.
- They are not considered a first-line treatment for **panic disorder** and are less effective than psychological therapies or SSRIs in treating the underlying condition.
*Commence escitalopram 10mg daily immediately*
- While **SSRIs** like escitalopram are a first-line pharmacological treatment for **panic disorder**, their therapeutic effects take several weeks to become evident and are not suitable for immediate symptom relief in an emergency setting.
- Initiation of long-term pharmacotherapy should ideally occur in a primary care setting following a comprehensive assessment and diagnosis of **panic disorder**.
*Arrange same-day psychiatric assessment*
- An immediate **emergency psychiatric assessment** is generally not required for isolated **panic attacks** once acute medical causes have been excluded, especially if there are no signs of psychosis or immediate risk to self or others.
- Appropriate follow-up for the management of recurrent panic attacks would typically involve referral to **primary care** for ongoing management or to **community mental health services** if specialized therapy is indicated.
Question 123: A 31-year-old man with generalised anxiety disorder has been experiencing excessive worry about work performance, finances, and family relationships for 8 months. He reports difficulty controlling the worry, muscle tension, poor concentration, and disturbed sleep. He declined medication initially. After completing a 10-week high-intensity CBT programme, his GAD-7 score has reduced from 18 to 15. What is the most appropriate next step in management?
A. Discharge with self-help materials
B. Repeat the CBT course with a different therapist
C. Commence sertraline and review in 4 weeks (Correct Answer)
D. Refer for psychodynamic psychotherapy
E. Commence pregabalin and review in 2 weeks
Explanation: ***Commence sertraline and review in 4 weeks***
- The patient's GAD-7 score of 15 indicates persistent moderate-to-severe anxiety despite completing a 10-week **high-intensity CBT** program, making pharmacological intervention necessary.
- **Sertraline** is a **first-line selective serotonin reuptake inhibitor (SSRI)** recommended for Generalised Anxiety Disorder (GAD) by clinical guidelines, with a **4-week review** being appropriate to assess initial response and tolerability.
*Discharge with self-help materials*
- Discharge is inappropriate given the patient's ongoing significant symptoms and a GAD-7 score of 15, which indicates continued **clinical impairment**.
- Self-help materials are part of **low-intensity interventions** (Step 2), which the patient has already progressed beyond by failing to improve with high-intensity therapy (Step 3).
*Repeat the CBT course with a different therapist*
- While therapist-client fit is important, there's no strong evidence to suggest that merely repeating an identical **10-week high-intensity CBT course** with a different therapist is the most effective next step after a previous failure.
- Guidelines typically recommend **stepping up treatment** to a different modality, such as pharmacotherapy, when a primary psychological intervention is insufficient.
*Refer for psychodynamic psychotherapy*
- **Psychodynamic psychotherapy** is not a recommended first-line or second-line treatment option for Generalised Anxiety Disorder in most major clinical guidelines (e.g., **NICE**).
- It lacks the robust evidence base demonstrated by **CBT** and **pharmacological treatments** like SSRIs for effective management of GAD.
*Commence pregabalin and review in 2 weeks*
- **Pregabalin** is generally considered a **second or third-line option** for GAD, typically used when first-line agents like SSRIs or SNRIs are ineffective or not tolerated.
- **SSRIs** are the initial pharmacological treatment of choice due to their established efficacy and favorable risk-benefit profile compared to pregabalin's potential for **dependence** and specific side effects.
Question 124: A 44-year-old woman presents with a 6-week history of low mood, reduced energy, and weight loss. She describes feeling worthless and guilty about minor past events. Her PHQ-9 score is 21. She has no past psychiatric history and takes no regular medications. Physical examination and routine blood tests are normal. What is the most appropriate first-line pharmacological treatment?
A. Venlafaxine
B. Fluoxetine
C. Amitriptyline
D. Mirtazapine
E. Sertraline (Correct Answer)
Explanation: ***Sertraline***
- **Selective Serotonin Reuptake Inhibitors (SSRIs)** like sertraline are the recommended first-line pharmacological treatment for **moderate-to-severe depression** (PHQ-9 ≥20).
- Sertraline is specifically favored due to its **cost-effectiveness**, lower risk of **drug-drug interactions**, and favorable safety profile.
*Venlafaxine*
- This is a **Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)** typically reserved for **treatment-resistant depression** after SSRIs have failed.
- It is associated with a higher risk of **hypertension** and more severe withdrawal symptoms compared to first-line agents.
*Fluoxetine*
- While an SSRI, it is generally preferred in **children and young people** or when a long half-life is specifically desired.
- In adult populations, **sertraline** or citalopram are often prioritized over fluoxetine in many clinical guidelines due to cost-effectiveness analyses.
*Amitriptyline*
- This is a **Tricyclic Antidepressant (TCA)** and is not first-line because of its high **toxicity in overdose** and significant side-effect burden.
- Common side effects include **anticholinergic effects** like dry mouth, blurred vision, and potential cardiac arrhythmias.
*Mirtazapine*
- This **NaSSA (Noradrenergic and specific serotonergic antidepressant)** is often used as a second-line agent or in patients with prominent **insomnia or weight loss**.
- Although effective, its side effects of **sedation and increased appetite** make it less common than SSRIs for initial treatment in most patients.
Question 125: A 36-year-old woman presents with symptoms suggestive of depression. She describes low mood, reduced appetite, poor sleep, and diminished interest in activities for the past 5 weeks. During assessment, which of the following symptoms would be classified as a 'biological' (somatic) symptom of depression according to ICD-10 criteria?
A. Reduced ability to experience pleasure (anhedonia)
B. Diurnal variation in mood with worsening in the morning (Correct Answer)
C. Feelings of worthlessness and guilt
D. Reduced concentration and attention
E. Recurrent thoughts of death
Explanation: ***Diurnal variation in mood with worsening in the morning*** - According to **ICD-10 criteria**, mood that is distinctly worse in the morning is a specific **somatic (biological) symptom** of depression. - Other recognized somatic symptoms include **early morning awakening**, significant **weight loss** (5% or more in a month), and objective **psychomotor agitation or retardation**. *Reduced ability to experience pleasure (anhedonia)* - Although it is a **core symptom** of depression, it is categorized as a psychological/emotional feature rather than a specific somatic symptom in the ICD-10 somatic syndrome classification. - It represents a lack of **emotional reactivity** to enjoyable surroundings but is distinct from the physiological changes like appetite or sleep disturbances. *Feelings of worthlessness and guilt* - These are considered **cognitive symptoms** of depression that reflect the patient's internal thought patterns and self-perception. - While they contribute to the diagnosis of a **depressive episode**, they do not fall under the **somatic syndrome** cluster. *Reduced concentration and attention* - This is a **cognitive impairment** symptom associated with depression that affects daily functioning and task performance. - It is not classified as a **biological symptom**, which typically involves alterations in **circadian rhythms** or physiological drives like hunger and sex. *Recurrent thoughts of death* - Suicidal ideation and thoughts of death are categorized as **psychological and behavioral** symptoms of severe depression. - These symptoms reflect the severity of the **depressive episode** but do not meet the criteria for **biological/somatic features** like diurnal mood variation.
Question 126: A 52-year-old man with chronic generalised anxiety disorder has failed to respond adequately to sertraline 150mg daily and two courses of CBT over the past 18 months. His GAD-7 score remains at 15 and symptoms significantly impact his work and relationships. He has no history of substance misuse. His renal function is normal. Which of the following would be the most appropriate next pharmacological option?
A. Switch to duloxetine
B. Add buspirone as augmentation
C. Switch to pregabalin (Correct Answer)
D. Add quetiapine as augmentation
E. Trial of benzodiazepines for 4 weeks
Explanation: ***Switch to pregabalin***
- **Pregabalin** is recommended by **NICE guidelines** for the treatment of **Generalised Anxiety Disorder (GAD)** if a patient cannot tolerate or does not respond to SSRIs or SNRIs.
- It has a distinct mechanism of action as a **voltage-gated calcium channel** ligand, making it a suitable next step after the failure of **Sertraline** and **CBT**.
*Switch to duloxetine*
- **Duloxetine** is an **SNRI** often used for GAD, but switching between first-line pharmacological classes (SSRI to SNRI) is generally considered after multiple initial failures or as an alternative to **Pregabalin**.
- In clinical practice, when an SSRI and intensive psychological therapy fail, **Pregabalin** is often prioritized due to its specific licensing and evidence base for treatment resistance.
*Add buspirone as augmentation*
- **Buspirone** is a 5-HT1A partial agonist that lacks robust evidence for effectiveness when used as an **augmentation agent** in treatment-resistant GAD.
- It is not a preferred next step in UK clinical guidelines compared to switching to an established monotherapy like **Pregabalin**.
*Add quetiapine as augmentation*
- **Quetiapine** is an atypical antipsychotic that carries a significant risk of **metabolic side effects**, including weight gain and impaired glucose tolerance.
- While used in specialist settings for refractory cases, it is not recommended for routine use in primary care or as a standard next step before trying **Pregabalin**.
*Trial of benzodiazepines for 4 weeks*
- **Benzodiazepines** are generally avoided in the long-term management of GAD due to high risks of **tolerance, dependence**, and withdrawal symptoms.
- They are only indicated for **short-term crisis management** (usually 2-4 weeks max) and do not address the underlying pathology in chronic treatment-resistant cases.
Question 127: A 45-year-old woman with moderate depression started on sertraline 50mg daily attends for review after 2 weeks. She reports nausea, loose stools, and increased anxiety. These symptoms started 3 days after beginning the medication. Her mood has not yet improved. She is considering stopping the medication due to side effects. What is the most appropriate management approach?
A. Stop sertraline immediately and switch to mirtazapine
B. Reduce sertraline dose to 25mg daily for 1 week then increase to 50mg
C. Continue current dose with reassurance that side effects typically improve within 1-2 weeks (Correct Answer)
D. Add propranolol to manage anxiety symptoms
E. Stop sertraline and arrange to restart after 1 week washout period
Explanation: ***Continue current dose with reassurance that side effects typically improve within 1-2 weeks***
- Side effects like **nausea**, **loose stools**, and **increased anxiety** are very common when starting **SSRIs** and typically resolve as tolerance develops within the first **forty-eight hours to two weeks**.
- Antidepressant **therapeutic benefits** usually take **2-4 weeks** to manifest, so the medication should not be discontinued before an adequate trial period has passed.
*Stop sertraline immediately and switch to mirtazapine*
- Switching medications is inappropriate until an **adequate trial** of the first-line agent has been completed or if side effects are truly **intolerable**.
- **Mirtazapine** has a different side effect profile (e.g., sedation and weight gain) but is generally reserved for patients who do not tolerate or respond to **SSRIs**.
*Reduce sertraline dose to 25mg daily for 1 week then increase to 50mg*
- While **dose titration** can sometimes help, the patient is already at a standard starting dose, and reduction may unnecessarily delay the time to reaching a **therapeutic level**.
- Reassurance is the preferred first step as most patients can successfully habituate to the **50mg dose** without tapering.
*Add propranolol to manage anxiety symptoms*
- **Propranolol** is used for the symptomatic relief of **physical anxiety symptoms** (like palpitations) but does not address the underlying transient side effects of SSRI initiation.
- It is better to manage patient expectations and provide **psychoeducation** rather than adding a second medication for a temporary side effect.
*Stop sertraline and arrange to restart after 1 week washout period*
- A **washout period** is not indicated for early side effects and would only serve to prolong the patient's **depressive episode** and delay treatment efficacy.
- Stopping and restarting often leads to a recurrence of the same **initial side effects**, which can negatively impact future **medication adherence**.
Question 128: A 33-year-old woman with panic disorder and agoraphobia has completed 12 weeks of cognitive behavioural therapy with exposure work. She reports significant improvement with reduced panic frequency and increased confidence in previously avoided situations. However, she still experiences occasional panic attacks (once every 2-3 weeks) and mild anticipatory anxiety. What is the most appropriate next step in her management?
A. Discharge with advice to self-manage using techniques learned
B. Offer further CBT sessions focusing on relapse prevention (Correct Answer)
C. Start an SSRI to address residual symptoms
D. Refer for psychodynamic psychotherapy
E. Prescribe diazepam for use during panic attacks
Explanation: ***Offer further CBT sessions focusing on relapse prevention*** - The patient has shown a **significant response** to Cognitive Behavioural Therapy (CBT), making it the most appropriate path to extend treatment to consolidate gains and manage **residual symptoms**. - Relapse prevention sessions target **anticipatory anxiety** and provide strategies to handle future setbacks, which are crucial for long-term maintenance after the initial 12 weeks.*Discharge with advice to self-manage using techniques learned* - Discharging the patient prematurely while she still experiences **active panic attacks** and anxiety increases the risk of a full clinical relapse. - Monitoring and **embedding skills** through a structured conclusion of therapy is necessary before moving to independent self-management.*Start an SSRI to address residual symptoms* - While **SSRIs** are first-line for panic disorder, they are typically introduced if psychological therapy fails or as an initial combined approach for severe cases. - Given the patient's **good progress** with psychotherapy alone, continuing the psychological approach is preferred over introducing medication side effects for mild residual symptoms.*Refer for psychodynamic psychotherapy* - **Psychodynamic psychotherapy** is not considered a first-line, evidence-based treatment for panic disorder and agoraphobia compared to CBT. - Shifting modalities when a patient is already **positively responding** to the current evidence-based framework is clinically counter-indicated.*Prescribe diazepam for use during panic attacks* - **Benzodiazepines** like diazepam are not recommended for long-term management as they can lead to **dependence and tolerance**. - They act as **safety behaviors**, which undermine the efficacy of CBT exposure work by preventing the patient from learning that panic sensations are not dangerous.
Question 129: A 59-year-old man with recurrent depressive disorder has been taking fluoxetine 40mg daily for 2 years following his third depressive episode. He has been well for 18 months and asks about stopping his medication. According to current NICE guidance, what is the minimum recommended duration of maintenance treatment after a third or subsequent episode of depression?
A. 6 months after remission
B. 12 months after remission
C. 18 months after remission
D. 24 months after remission
E. Indefinite treatment should be considered (Correct Answer)
Explanation: ***Indefinite treatment should be considered***
- For patients with **three or more episodes** of depression (recurrent depressive disorder), the risk of relapse is over **90%**, necessitating long-term maintenance.
- NICE guidelines recommend that such patients continue antidepressant treatment for at least **2 years** at the dose that led to remission, with strong consideration for **indefinite therapy** to prevent further recurrences.
*6 months after remission*
- This duration is typically reserved for a **first-time episode** of depression to reduce the risk of immediate relapse.
- It is insufficient for recurrent depression, where the risk of **clinical deterioration** is significantly higher.
*12 months after remission*
- While some guidelines suggest this for a **second episode** with specific risk factors, it is not the standard for a third or subsequent episode.
- Discontinuing at this stage in high-risk patients often leads to **treatment failure** and a rapid return of symptoms.
*18 months after remission*
- This matches the patient's current duration of wellness, but it falls short of the minimum **24-month guideline** for high-risk individuals.
- Stopping now would ignore the **cumulative risk** associated with having had three separate depressive episodes.
*24 months after remission*
- While antidepressant treatment must be continued for at least **2 years** following remission after a third episode, the ultimate recommendation for such high-risk patients is often to consider **indefinite treatment**.
- 24 months serves as a benchmark for review, but the clinical focus remains on **long-term prevention** rather than a fixed end-date, making indefinite treatment the more comprehensive answer.
Question 130: A 37-year-old man with panic disorder describes that his panic attacks are always triggered by being in crowded places, particularly supermarkets and public transport. He has been avoiding these situations for 3 months. He has no unexpected panic attacks. His avoidance is significantly impacting his daily functioning. Which diagnosis best describes his presentation?
A. Panic disorder with agoraphobia
B. Agoraphobia without history of panic disorder (Correct Answer)
C. Specific phobia (situational type)
D. Social anxiety disorder
E. Generalised anxiety disorder with panic attacks
Explanation: ***Agoraphobia without history of panic disorder***- The patient experiences panic attacks that are exclusively **situationally bound** or triggered by specific environments like crowds and public transport, rather than **spontaneous/unexpected** attacks.- According to diagnostic criteria, if panic attacks only occur in response to agoraphobic triggers and there is no history of **unprovoked attacks**, the primary diagnosis is **Agoraphobia**.*Panic disorder with agoraphobia*- **Panic disorder** requires the presence of recurrent, **unexpected panic attacks** that occur "out of the blue."- Since this patient has **no unexpected attacks** and symptoms are strictly triggered by specific situations, this diagnosis is excluded.*Specific phobia (situational type)*- Specific phobia typically involves a fear of a **single, specific situation** (e.g., flying or heights) rather than a cluster of situations.- This patient avoids multiple distinct scenarios like **supermarkets AND public transport**, which fulfills the broader avoidance criteria of **agoraphobia**.*Social anxiety disorder*- Social anxiety is centered on a fear of **social scrutiny**, embarrassment, or being judged by others.- The patient's avoidance is driven by the fear of the **panic symptoms** themselves and the difficulty of escape, rather than a fear of negative evaluation by others.*Generalised anxiety disorder with panic attacks*- **GAD** is characterized by persistent, excessive worry regarding **multiple different domains** (e.g., work, health, finances) for at least 6 months.- This presentation is focused specifically on **situational triggers** and panic symptoms, not the pervasive "free-floating" anxiety typical of GAD.
